Chapter 41: Gastrointestinal Dysfunction Nursing School Test Banks

Chapter 41: Gastrointestinal Dysfunction

MULTIPLE CHOICE

1. Nurses must be alert for increased fluid requirements when a child has:

a.

Fever.

c.

Congestive heart failure.

b.

Mechanical ventilation.

d.

Increased intracranial pressure (ICP).

ANS: A

Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1255

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. Which type of dehydration results from water loss in excess of electrolyte loss?

a.

Isotonic dehydration

c.

Hypotonic dehydration

b.

Isosmotic dehydration

d.

Hypertonic dehydration

ANS: D

Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1256

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of:

a.

Overhydration.

c.

Sodium excess.

b.

Dehydration.

d.

Calcium excess.

ANS: B

These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1256

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. Acute diarrhea is often caused by:

a.

Hirschsprungs disease.

c.

Hypothyroidism.

b.

Antibiotic therapy.

d.

Meconium ileus.

ANS: B

Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprungs disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1259

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. The viral pathogen that frequently causes acute diarrhea in young children is:

a.

Giardia organisms.

c.

Rotavirus.

b.

Shigella organisms.

d.

Salmonella organisms.

ANS: C

Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1260

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. A parasite that causes acute diarrhea is:

a.

Shigella organisms.

c.

Giardia lamblia.

b.

Salmonella organisms.

d.

Escherichia coli.

ANS: C

Giardia is a parasite that represents 15% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1273

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition?

a.

Protein intolerance

c.

Fat malabsorption

b.

Parasitic infection

d.

Bacterial gastroenteritis

ANS: D

Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1263

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. Therapeutic management of the child with acute diarrhea and dehydration usually begins with:

a.

Clear liquids.

b.

Adsorbents such as kaolin and pectin.

c.

Oral rehydration solution (ORS).

d.

Antidiarrheal medications such as paregoric.

ANS: C

ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheals because they do not get rid of pathogens.

PTS: 1 DIF: Cognitive Level: Application REF: 1263

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with:

a.

Intravenous fluids.

b.

Oral rehydration solution (ORS).

c.

Clear liquids, 1 to 2 ounces at a time.

d.

Administration of antidiarrheal medication.

ANS: A

Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

PTS: 1 DIF: Cognitive Level: Application REF: 1265

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies, which are now being successfully treated with antihistamines. The nurse should suspect that the constipation is most likely caused by:

a.

Diet.

c.

Antihistamines.

b.

Allergies.

d.

Emotional factors.

ANS: C

Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1266

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

11. A high-fiber food that the nurse could recommend for a child with chronic constipation is:

a.

Popcorn.

c.

Muffins.

b.

Pancakes.

d.

Ripe bananas.

ANS: A

Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas and avocados are high in fiber.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1251

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

12. Therapeutic management of most children with Hirschsprungs disease is primarily:

a.

Daily enemas.

b.

Low-fiber diet.

c.

Permanent colostomy.

d.

Surgical removal of affected section of bowel.

ANS: D

Most children with Hirschsprungs disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprungs disease is usually temporary.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1268

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. A 3-year-old child with Hirschsprungs disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is:

a.

Not necessary because of childs age.

b.

Not necessary because the colostomy is temporary.

c.

Necessary because it will be an adjustment.

d.

Necessary because the child must deal with a negative body image.

ANS: C

The childs age dictates the type and extent of psychologic preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms with the use of visual aids. It is necessary to prepare this age child for procedures. The preschooler is not yet concerned with body image.

PTS: 1 DIF: Cognitive Level: Application REF: 1268

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

14. The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. The nurse should include:

a.

Avoiding carbohydrate-containing liquids.

b.

Giving nothing by mouth for 24 hours.

c.

Brushing teeth or rinsing mouth after vomiting.

d.

Giving plain water until vomiting ceases for at least 24 hours.

ANS: C

It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Administration of a glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1269

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

15. A 4-month-old infant has gastroesophageal reflux disease (GERD) but is thriving without other complications. What should the nurse suggest to minimize reflux?

a.

Place in Trendelenburg position after eating.

b.

Thicken formula with rice cereal.

c.

Give continuous nasogastric tube feedings.

d.

Give larger, less frequent feedings.

ANS: B

Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.

PTS: 1 DIF: Cognitive Level: Application REF: 1270

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. A histamine receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux. The purpose of this is to:

a.

Prevent reflux.

c.

Reduce gastric acid production.

b.

Prevent hematemesis.

d.

Increase gastric acid production.

ANS: C

The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. Preventing reflux and hematemesis and increasing gastric acid production are not the modes of action of histamine receptor antagonists.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1282

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. Which clinical manifestation would most suggest acute appendicitis?

a.

Rebound tenderness

b.

Bright red or dark red rectal bleeding

c.

Abdominal pain that is relieved by eating

d.

Abdominal pain that is most intense at McBurneys point

ANS: D

Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurneys point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1275

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. When caring for a child with probable appendicitis, the nurse should be alert to recognize that a sign of perforation is:

a.

Bradycardia.

c.

Sudden relief from pain.

b.

Anorexia.

d.

Decreased abdominal distention.

ANS: C

Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1275

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. Which statement is most descriptive of Meckels diverticulum?

a.

It is more common in females than in males.

b.

It is acquired during childhood.

c.

Intestinal bleeding may be mild or profuse.

d.

Medical interventions are usually sufficient to treat the problem.

ANS: C

Blood stools are often a presenting sign of Meckels diverticulum. It is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckels diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1275

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

20. What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus?

a.

Crohns disease

c.

Meckels diverticulum

b.

Ulcerative colitis

d.

Irritable bowel syndrome

ANS: A

The chronic inflammatory process of Crohns disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckels diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1278

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

21. What is used to treat moderate-to-severe inflammatory bowel disease?

a.

Antacids

c.

Corticosteroids

b.

Antibiotics

d.

Antidiarrheal medications

ANS: C

Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1279

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

22. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to:

a.

Eradicate Helicobacter pylori.

c.

Treat epigastric pain.

b.

Coat gastric mucosa.

d.

Reduce gastric acid production.

ANS: A

This combination of drug therapy is effective in the treatment and eradication of H. pylori.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1282

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

23. Which statement best characterizes hepatitis A?

a.

The incubation period is 6 weeks to 6 months.

b.

The principal mode of transmission is through the parenteral route.

c.

Onset is usually rapid and acute.

d.

There is a persistent carrier state.

ANS: C

Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid acute onset. The incubation period is approximately 3 weeks for hepatitis A. The principal mode of transmission for hepatitis A is the fecal-oral route. Hepatitis A does not have a carrier state.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1283

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

24. The best chance of survival for a child with cirrhosis is:

a.

Liver transplantation.

c.

Treatment with immune globulin.

b.

Treatment with corticosteroids.

d.

Provision of nutritional support.

ANS: A

The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures, such as treatment with corticosteroids or immune globulin and nutritional support, to prevent or treat cirrhosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1287

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

25. The earliest clinical manifestation of biliary atresia is:

a.

Jaundice.

c.

Hepatomegaly.

b.

Vomiting.

d.

Absence of stooling.

ANS: A

Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1288

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

26. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initialtherapeutic approach to the mother should be to:

a.

Restate what the physician has told her about plastic surgery.

b.

Encourage her to express her feelings.

c.

Emphasize the normalcy of her baby and the babys need for mothering.

d.

Recognize that negative feelings toward the child continue throughout childhood.

ANS: B

For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infants physical needs but also on the parents emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur. Although discussing plastic surgery will be addressed, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurses actions should convey to the parents that the infant is a precious human being. The childs normalcy is emphasized, and the mother is assisted to recognize the childs uniqueness. A focus on abnormal maternal-infant attachment would be inappropriate at this time.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1290

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

27. Caring for the newborn with a cleft lip and palate before surgical repair includes:

a.

Gastrostomy feedings.

b.

Keeping the infant in near-horizontal position during feedings.

c.

Allowing little or no sucking.

d.

Providing satisfaction of sucking needs.

ANS: D

Using special or modified nipples for feeding techniques helps to meet the infants sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infants head in an upright position. The child requires both nutritive and nonnutritive sucking.

PTS: 1 DIF: Cognitive Level: Application REF: 1290

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

28. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infants postoperative care include:

a.

Arm restraints, postural drainage, and mouth irrigations.

b.

Cleansing of suture line, supine and side-lying positions, and arm restraints.

c.

Mouth irrigations, prone position, and cleansing of suture line.

d.

Supine and side-lying positions, postural drainage, and arm restraints.

ANS: B

The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1291

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

29. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include:

a.

Elevating the head but giving nothing by mouth.

b.

Elevating the head for feedings.

c.

Feeding glucose water only.

d.

Avoiding suctioning unless the infant is cyanotic.

ANS: A

When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1292

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

30. Which type of hernia has an impaired blood supply to the herniated organ?

a.

Hiatal hernia

c.

Omphalocele

b.

Incarcerated hernia

d.

Strangulated hernia

ANS: D

A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1294

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

31. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

a.

Abdominal rigidity and pain on palpation

b.

Rounded abdomen and hypoactive bowel sounds

c.

Visible peristalsis and weight loss

d.

Distention of lower abdomen and constipation

ANS: C

Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.

PTS: 1 DIF: Cognitive Level: Application REF: 1294

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

32. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to:

a.

Notify the practitioner.

b.

Measure abdominal girth.

c.

Auscultate for bowel sounds.

d.

Take vital signs, including blood pressure.

ANS: A

Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1297

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

33. An important nursing consideration in the care of a child with celiac disease is to:

a.

Refer to a nutritionist for detailed dietary instructions and education.

b.

Help the child and family understand that diet restrictions are usually only temporary.

c.

Teach proper hand washing and Standard Precautions to prevent disease transmission.

d.

Suggest ways to cope more effectively with stress to minimize symptoms.

ANS: A

The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1302

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

34. An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include:

a.

Preparing the family for impending death.

b.

Teaching the family signs of central venous catheter infection.

c.

Teaching the family how to calculate caloric needs.

d.

Securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

ANS: B

During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1303

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

35. For what clinical manifestation should a nurse be alert when suspecting a diagnosis of esophageal atresia?

a.

A radiograph in the prenatal period indicates abnormal development.

b.

It is visually identified at the time of delivery.

c.

A nasogastric tube fails to pass at birth.

d.

The infant has a low birth weight.

ANS: C

Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1291

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

36. What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux?

a.

Teach parents to position the infant on the left side.

b.

Reinforce the parents knowledge of the infants developmental needs.

c.

Teach the parents how to do infant cardiopulmonary resuscitation (CPR).

d.

Have the parents keep an accurate record of intake and output.

ANS: C

Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes the risk for aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 1271

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

37. What is the major focus of the therapeutic management for a child with lactose intolerance?

a.

Compliance with the medication regimen

b.

Providing emotional support to family members

c.

Teaching dietary modifications

d.

Administration of daily normal saline enemas

ANS: C

Simple dietary modifications are effective in the management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. Medications are not typically ordered in the management of lactose intolerance. Providing emotional support to family members is not specific to this medical condition. Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1254

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

38. What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching?

a.

Oatmeal

c.

Corn muffin

b.

Rice cake

d.

Meat patty

ANS: A

The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

PTS: 1 DIF: Cognitive Level: Application REF: 1302

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

39. Which intervention should be included in the nurses plan of care for a 7-year-old child with encopresis who has cleared the initial impaction?

a.

Have the child sit on the toilet for 30 minutes when he gets up in the morning and at bedtime.

b.

Increase sugar in the childs diet to promote bowel elimination.

c.

Use a Fleet enema daily.

d.

Give the child a choice of beverage to mix with a laxative.

ANS: D

Offering realistic choices is helpful in meeting the school-age childs sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia, and are used only during periods of fecal impaction.

PTS: 1 DIF: Cognitive Level: Application REF: 1266

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

40. Which description of a stool is characteristic of intussusception?

a.

Ribbon-like stools

c.

Currant jelly stools

b.

Hard stools positive for guaiac

d.

Loose, foul-smelling stools

ANS: C

Pressure on the bowel from obstruction leads to passage of currant jelly stools. Ribbon-like stools are characteristic of Hirschsprungs disease. With intussusception, passage of bloody mucus-coated stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1276

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

41. What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis?

a.

Preventing the spread of illness to others

b.

Nutritional guidance and preventing constipation

c.

Teaching daily use of enemas

d.

Coping with stress and avoiding triggers

ANS: D

Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.

PTS: 1 DIF: Cognitive Level: Application REF: 1278

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

42. Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings?

a.

Irritable bowel syndrome

c.

Hepatic cirrhosis

b.

Ulcerative colitis

d.

Hepatitis A

ANS: D

Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis is not infectious. Cirrhosis is not infectious.

PTS: 1 DIF: Cognitive Level: Application REF: 1283

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

43. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurses response should be based on knowledge that this drug is:

a.

Not indicated.

b.

Indicated because it slows intestinal motility.

c.

Indicated because it decreases diarrhea.

d.

Indicated because it decreases fluid and electrolyte losses.

ANS: A

Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1265

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

44. Which vaccine is now recommended for the immunization of all newborns?

a.

Hepatitis A vaccine

c.

Hepatitis C vaccine

b.

Hepatitis B vaccine

d.

Hepatitis A, B, and C vaccines

ANS: B

Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1284

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

45. During the first few days after surgery for cleft lip, which intervention should the nurse do?

a.

Leave infant in crib at all times to prevent suture strain.

b.

Keep infant heavily sedated to prevent suture strain.

c.

Remove restraints periodically to cuddle infant.

d.

Alternate position from prone to side-lying to supine.

ANS: C

The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.

PTS: 1 DIF: Cognitive Level: Application REF: 1291

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

46. An infant with pyloric stenosis experiences excessive vomiting that can result in:

a.

Hyperchloremia.

c.

Metabolic acidosis.

b.

Hypernatremia.

d.

Metabolic alkalosis.

ANS: D

Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1294

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

47. Which statements regarding hepatitis B are correct (Select all that apply)?

a.

Hepatitis B cannot exist in a carrier state.

b.

Hepatitis B can be prevented by hepatitis B virus vaccine.

c.

Hepatitis B can be transferred to an infant of a breastfeeding mother.

d.

The onset of hepatitis B is insidious.

e.

Immunity to hepatitis B occurs after one attack.

ANS: B, C, D, E

The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mothers nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state.

PTS: 1 DIF: Cognitive Level: Application REF: 1283

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

48. Which interventions should a nurse implement when caring for a child with hepatitis (Select all that apply)?

a.

Provide a well-balanced, low-fat diet.

b.

Schedule playtime in the playroom with other children

c.

Teach parents not to administer any over-the-counter medications.

d.

Arrange for home schooling because the child will not be able to return to school.

e.

Instruct parents on the importance of good hand washing.

ANS: A, C, E

The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital, so playtime with other hospitalized children is not scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of jaundice. After that period, the child will be allowed to return to school.

PTS: 1 DIF: Cognitive Level: Application REF: 1286

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

49. The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing (Select all that apply)?

a.

Nothing by mouth for 24 hours

b.

Administration of analgesics for pain

c.

Ice bag to the incisional area

d.

Intravenous (IV) fluids continued until tolerating fluids by mouth

e.

Clear liquids as the first feeding

ANS: B, D, E

Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing.

PTS: 1 DIF: Cognitive Level: Application REF: 1294

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

50. A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber (Select all that apply)?

a.

White rice

b.

Avocados

c.

Whole grain breads

d.

Bran pancakes

e.

Raw carrots

ANS: C, D, E

High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1266

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

51. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply):

a.

Giving medication to suppress lactation.

b.

Encouraging and helping mother to breastfeed.

c.

Teaching mother to feed breast milk by gavage.

d.

Recommending use of a breast pump to maintain lactation until infant can suck.

ANS: B, D

The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infants oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 1290

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

52. A child has a nasogastric (NG) tube to continuous low intermittent suction. The physicians prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the previous 4 hours totaled 50 mL. What milliliter/hour rate should the nurse administer to replace with a normal saline piggyback? _____ Record your answer as a whole number.

ANS:

25

The previous total 4-hour output was 50 mL. To run the 50 mL over a 2-hour period, the nurse would divide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 mL/hr.

PTS: 1 DIF: Cognitive Level: Application REF: 1256

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

MATCHING

The school nurse observes a child with a peanut allergy in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority.

a.

Call Jasons parents and notify them of the situation.

b.

Call Jasons family practitioner to obtain further orders for medication.

c.

Promptly administer an intramuscular (IM) dose of epinephrine.

d.

Call 911 and wait for the emergency response personnel to arrive.

53. First priority

54. Second priority

55. Third priority

56. Fourth priority

53. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 1252 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

54. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 1252 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

55. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 1252 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

56. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 1252 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

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